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24460 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPER'CINO HUILUINC-ELKC'TRICAI. PERMIT NO. APPLICATION/PERMIT PING PROO-MECHANICAS FICA 24460_ BUILDING DIVISION BUILDING PNOJRC"1'IDEN'TIFICA'TION UILDING ADDRES SANITARY NO. APPLICATIOO4NsuB/^M�DTN ALDE R3 "AgZj"Al Al' UNIT# LOT# S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'. iiY 1. ALAE Q / N/C CONTROL# R HITS-C'DENGINEER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO G PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DESCRIPTION pUV Ihcrthy affirm ofDryihatl 3 of the underprovisionsPi innsions Code.and(commencing with FO VO Scdiun]OWIof Uivisi0n3 of the Husinesx and Prolcssions Code,and my license is in PANELS C full force and effect. iOL a.,2W Liccms,Class Lic.# UP TO 200 AMPS Fjvai Data Commetne 201-10(1(1 AMPS TOy= ARCHITECTS DECLARATION OVER 1(X10 AMPS ) SQ.FT.FLOOR AR EA $/SQ.FT, OZ-0 Iande...andmy p1.rs,hall be used as pablicreeorde. © IN P y F w SIGNS ELECTRICAL Q�=Q Licensed Professional OWNER BUILDER DECLARATION SPECIAL CIRCUFUMISC. uKoav 1 Hereby are that 1 am exempt from the cantmetarx License Law roe meJXA �' ER =LLOQ following reasnn.(Stai.7031.5,Business and Professions Code:Anycity orcounty TEMP.METER OR POLE INST. 1 which require%apcnnittocommart,alter.improve.demolish,or repair any sanctum DTE / 2, !jZ ='�Qf Prior m it issuance,also requlas theapplicam far such permit to file.signedsutemem POWER DEVICES fy Eppm thin he is licensed putsuam nu he provi,i.nsof the Comoscanes License Law(Chapter d KOLL 9(commencing with Section]000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC V N W_N .mathat 7031.5exempt therefrom ii,nicand me conf0rthecos thedexemant to Any Ipen violation of OUTLETS-SWITCHES-FIXTURES �OOQ Section than by onynhood for a npplicanunuCivil#smolt f VV���JJJJ not are than Hoe hundred dollars(5500). WFp I,as n y employees g compensation. NEW RESIDENTIAL ELECfR FT. ttii]]gqe props y,0rm em I0 eeswith wages —SQ. STORIES TYPO CONSTHUCIIfIN andWufswank.andthe he Contratorcons, awdoes not apply to an,Business pro professions Cade:The vesthenon,License Law docs or apply to it roughs iof s own enywho s,prove ed that sucherton,and entsamwhodos such work oro(fa onnrovgh M1f. ear,thees,progori improvement is fuevle.If. OCC GROUP RFS.UNITS however,the building or improvement is sold within one year of completion,the owner- bewill have the hurdcn of proving that he did not build or improve for purpose of TO safe.). ❑ 1,as the c h (See.tiny.,Boom,, ad Pod fonanu with The ontracnm QTY. PLUMBING PERMIT FEF, FLOOD ZONE APN mgse w pmjcct(gee.oano easiness and ywhobuild Cadc:)The Contractor's License Law Jforsucapply rijeonwith ac mmatoeny whesed pursuant tithe ommeand PERMIT ISSUANCE who conuaw,fersuch projcas with a comracmr(s)licensed pursuant mthe Cnmmctnr's hicenu Law. ALTER.DRAIN&VENT-WATER(EA) FEE SUMMARY ❑ 1 am exempt under Sec. B&P C for this rtawn BACK FLOW PROTECT.DEVICE OUTSIDE PETS Owacr• Date SANITARY Y N WORKMAN COMPENSATION DECLARATION DRAINS.FLOOR.ROOF,AREA,COND. RECEIPT# j SCHOOL.TAX N ❑ Iherchy.Teter that lhave accnifca¢of e0nsenno self-insure.nracenYifcatc of FIXTURES-PER TRAP RLCEIPI'p Workers'Compersionn lmsoraerem acenifad copy thereof(See.JSW,feb CJ which / PARK FEE Y N_ covers all empermit.employee's under this pit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPI'# Policy N BUILDING DIVISION FEES Company ❑ CenifieJ copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE ❑ CmifcJ mpy is tried with the city impcction Division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATEOF EXEMPTION FROM WORKERS' CREASF,'INAP SOILS PEE COMPENSATION INSURANCE (This section need not be completed ifthe permit is forone hundred dollan($100) SEWER-SANITARY-STORM EA.2WFT. or 13NERGY FEE lc .) I anify that in the perfosmance of the week for which this#mon,is ismed,I shot 1 WATER HEATER W/VP/ELECfR not employ may person in any manner m n to become subpart to the Worker.' PAID Cimerian Lawsof C.lihmia. Date WATER SYSTEM/TREATING z Applicant Date Receipt# Q z 2 NOTICE TO APPLICANIF If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. AIIIA r .fir become subject to the Worker's Compensation provisions of the Labor Code you must a > forthwith comply with such provisions aphis permit shall be deemed revoked. SBNCG FEE 1 M CONSTRUCTION LENDING AGENCY FEEZD I hereby affirm thatthem is a conswetion lending agency for the pcommosence of Othe work for which his permtit is issaal(Sae.309],Civ.CJ FEEI Leader's Name O U lander.Address QTYaTO L PERMIT FEE G FEE1 certify that 1 have mad his application and state that the above iformmi0n a 0. e0rrttt. lagreemenmplY with till city and county ardinanen and store lawudating to �. CAL FEE rA building construction,and herchy outhonze repasenmtiveso(this city m enter upon the (J z above-mentioned property for inspection purgtus. H. CTIONTAX (We)agree to save.indemnify and keep M1mmlcs,me City of Cupertino against initial ties,ju cots,roots and expenses which may in any wayacrow.gainst xui City G IB,IXX)CFM) usec of the grantirtg_of this Pc nn' 9 AIR HANDLING UNIT(OVER 10,(100 CFM) Signmare of ApplannUComra tur ate EXHAUST HOOD(W/DUCD PAID HA%ARDOUSMATER AL DISCLOSURE HEATING UNIT(10 100.000 BTU) Date Rettiptp Will the applicant or future building occupant store or handle hazvdous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hwhh and Safety HEATING UNIT(OVER I W,"BTU) Code.Section 25532(.)'1 ❑Yes 0N VENTILATION FAN(SINGLE RESID) Will the applicantorfmum buildingescupant use equipmentordeviceswhichemit BOILER-COMP(3HPORI00,000BTU) ISSUANCE DATE hat,airdtf Diwrktus air contaminations as deffneJ by the Bay Acre Uisnictl Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A B D ❑Yes ❑No NEW RESIDENTIALMECIL SQ,Ff. NOV1 have read the hazardous materials requirements under Chapter 6.95 of he 9 1992 Califomi.l lealth&Safety Cale.Sections 25505.25533 and 25534. I undersand that if the builJing J�Ms nm currently haveatcnant.that it is my responsihility to notify the 611 Y ser l:f n-r- mcupam of the requirement which must twmet prior t0 issuance of a CenlBcate of �fl I IIVV Occupancy. \��/���,r\( Owner or amir imtlagem Data Y �� ISSUED BY_ `aVY� T OFFICE